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<br />~ <br />~~HILLS <br /> <br />City of Arden Hills <br />1245 West Highway 96 <br />Arden Hills, Minnesota 55112 <br />Phone: 651.792.7800 <br />Fax: 651.634.5137 <br />www.cLarden-hills.mn.us <br /> <br /> <br />License No. GAM08- <br />Receipt No. <br />Amount Paid $150.00 <br />Date Recvd. <br />Ins. Cert <br />Total Fee Paid <br /> <br />2008 Charitable Gambling Premise Permit- <br /> <br />Application Form <br />(Terms of the License: 2 Year Agreement) <br /> <br /> <br />Information (aI/fields are required) <br /> <br />Business Name: <br /> <br />)1'". fVlt-K Y I2OfJ1IAlI4tL-.u. ,::1".Jf,:)DoX <br />1117(, GAltJ€j.,L( .-fvL <br /> <br />cflu pc./l <br /> <br />Property Address: <br /> <br />I <br /> <br />Nature of Business: <br /> <br />__I} \ tV (; o__JiA L t- <br />ree:; !J1-,uSJ-4.I------ <br /> <br />Local Contact: <br /> <br />---K-E-Uf- <br />. (.1' ( (,J(---j.1-.L4-~ <br /> <br />Business Fax: <br /> <br />Business Phone: <br /> <br />Email Address: <br /> <br />Webs!te Address: <br /> <br />Federal ID#: <br /> <br />-3i~-i'=l4jY.14---- <br /> <br />Premise Permit and Investigation Fee <br /> <br />\i"- <br />$1OO.QQ <br /> <br />*2007 Income and Loss Statement <br />*Projected 2008 Receipts/Prizes <br />*Copy of Lease Agreement <br /> <br />(All organizations pennitted to conduct lawful gambling within the City of Arden Hills shall contribute 10% (ten percent) of their <br />net profits derived from gambling activities within the City to a special fund to be administered by the City Council for lawful <br />purposes. Pa)TI1ents to the fund shall be calculated for quarterly periods ending -on the last days of March, June, September and <br />December. Quarterly installment payments shall be submitted together with verifiable supporting documentation no later than the <br />twentieth day of the month following the end of the quarterly period.) <br /> <br />Authorized SigllilturedPll,;;KJ-0Vl11':'- <br /> <br />Datel:IJ-~Qt <br /> <br />Received <br />JAN 1 5 Z008 <br /> <br />City of Arden Hills <br />